Tom, I felt compelled to write. I am a quality manager for a very large independant chain of homes (80 homes). We audit 100% clinical, activities, medication, personnel twice a year. We also ask views of residents/families doctors/social services and also look at meal/music/TV perferences etc once per year to see if there are any problems. I have worked this company since the beginning and there are so many controls that it would make you weep. I also change my audit trail all the time i.e. looking at weight decrease and increase. I ask for resident views at time of visit to see if they are content and happy. I have recently asked all staff to taken photos and all baseline obs of all residents being admitted to hospital as sometimes the deterioration in their condition whilst in hospital is great and the blame is always put on the homes. Yes i do sometimes have rogue managers however as with any other large organisation we talk all the time and can see straight away when the home is not performing and we can put pressure on that manager to perform or get out. That is the benefit of a large organisation - I can put a performing manager straight away in one of the underperforming homes. I always say that if the home manager is good then they will lead from above. I recently had my mother last year in hospital with two strokes and two leg amputations. The care was atrocious, I requested care notes six times and none came through. In the end both myself and the consultant (another female!) were in tears as to her condition. To end it all she got MRSA. I did not see any controls once or hand washing. I am passionate about what I do and I feel so are my colleagues. I worked for the owners when they had two homes and they never took out a penny for years. Yes they are beginning to reap some benefits but if you look at any of the homes ou will see improvements taking place. We have quality system - inviting external inspectors into the company on a monthly basis and are starting to go green! as well as CSCI And I do not earn that much! And none of my homes are in your area! And I bought your book and have been reading your blog for ages!